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Public health implications of Trump’s decision to terminate the US relationship with WHO in sub-Saharan Africa and how to mitigate them in the short term

By Hiwote Solomon
on June 2, 2020

Last week, after more than a month of thinly and less thinly veiled threats, President Trump announced the U.S. would “terminate” its relationship with the WHO. As if he was playing in his own Terminator movie, a really bad sequel at that. It is not immediately clear whether the president can fully withdraw U.S. funding from WHO without an act of Congress, which typical controls all federal government spending. Some have also questioned whether it is even legally possible for Trump to withdraw from WHO, while others have noted that U.S. law requires the country to pay any outstanding dues to the agency before withdrawing. In spite of this somewhat murky picture, it seems highly likely, however, that the Trump administration will do everything it can to implement this decision. Especially given the current domestic political environment with a presidential election around the corner. If the administration is successful in its efforts, sooner or later there will be no more US funding for WHO, at least not until another administration takes over. 

The United States is currently the WHO’s biggest donor, having pledged $893 million (15% of the overall WHO budget) during the organization’s 2018-2019 budget cycle. As noted by others, losing this funding would have dire effects on many low- and middle-income countries (LMICs). For example, a quarter of WHO funding to the African Region comes from the United States’ contribution to the organization.  The full range of the consequences of the United States halting its WHO funding is difficult to assess, but it is clear that there will be a significant impact on health systems in Africa, with many already overburdened with communicable diseases and limited resources. The impact on the global polio eradication program will especially be grave.

Three months of Covid-19 in SSA

Meanwhile, despite having been spared some of the most dire scenarios in the first wave of infections, a number of countries in Africa are also facing an exponential rise in COVID-19 cases. Three months after sub-Saharan Africa confirmed its first case,  25 countries in the region experience community transmission. As a Lancet editorial put it last week, there’s certainly “no room for complacency”. A recent WHO African Region modeling study estimates that about 22% of the 1 billion that reside in the region will be infected in the first year of COVID-19. Mitigation efforts will continue to strain already weak health systems, especially at the secondary and tertiary levels. The WHO African Region COVID-19 Readiness Status also paints a bleak picture with only half of countries reporting they had personal protective equipment available. Further, the entire continent has about 5000 critical beds available and lacks sufficient ventilators, with countries such as Sierra Leone reporting only 18 ventilators for their entire population of 7.65 million. And let’s not forget about dire oxygen supply and systems in the first place.   

If the US pulls out of WHO altogether, in essence that also implies they pull out of global efforts to assist with the COVID-19 response in sub-Saharan Africa. The new global health security/pandemic response initiative the US seems to be considering, if it ever sees the light in the first place, will unlikely be able to fill the expected void as it will lack the expertise and contacts to help on the ground, certainly in the near future. As for other global health organisations (to which some of the funding would be redirected, according to Trump),  in the words of  Ashish Jha, “ none has the expertise, capacity for coordination, and leverage as the WHO.”  

In addition to Covid-19, there are also a number of other outbreaks strewn across the continent, as always. Late last year, for example, the WHO and partners identified nine new cases of vaccine-derived polio in Nigeria, the Democratic Republic of  Congo, Central African Republic, and Angola. The Independent Monitoring Board of the Global Polio Eradication Initiative flagged in its latest report (November 2019), “Vaccine-derived poliovirus is moving across Africa…”. In addition to polio & Covid-19, the continent faces plenty of other outbreaks  (measles, cholera, dysentery, malaria and hemorrhagic fever, …), for an overview, see the latest  WHO Afro Bulletin on outbreaks and other emergencies  (31 May).  Almost 40% of the WHO Africa Region’s polio eradication initiatives are funded through the United States’ contribution to WHO, and they are often integrated with other health programs. The effects of a halt in funding will thus reverberate across programmatic and disease areas.

Who can fill the funding gap in the short term?

As noted by many, the U.S. relation with the WHO extends beyond funding. For now, however, given that it’s rather unlikely Trump will fulfill any remaining funding commitments to WHO in the months ahead, a key question seems: who, if anyone, will step up to fill the funding gap the U.S. leaves behind? While there is some hope that a new administration in the U.S. will re-establish the funding to (and relationship with) the WHO, that option is far from guaranteed, especially given the current political instability in the U.S., now increasingly looking like a ‘failed state’ itself. Further, the health programs in LMICs, including many African countries, affected by the suspension of funding do not have the luxury to wait for a change in administration in the U.S., especially as the threat of COVID-19 continues.  

One option to fill the funding gap, in the short term at least, is for philanthropic entities, including African philanthropists, to match the suspended funding. There is precedence for such action.  In 2017, Michael Bloomberg pledged $15 million  to help make up for the climate agreement funding shortfall caused by the Trump administration’s announcement to pull out of the Paris Agreement – picking up “the US bill” so to speak. The time is now to do the same for U.S. and African billionaires and philanthropists who care about global health. One “usual suspect” for such action would be the Bill & Melinda Gates Foundation, of course, currently the biggest donor to the WHO after the U.S. The philanthropic organization’s contribution accounts for almost 10% of the WHO’s funding. However, that relationship is already rather “controversial”, to put it mildly. Thus, it is better if other (and preferably African) billionaires step up to the challenge – ideally, “with no billionaire strings attached”. For example, African billionaire Aliko Dangote has in the past committed to help eradicate polio and malnutrition in Nigeria. Dangote has also been active during the COVID-19 pandemic, pledging 2 billion Nigerian Naira. We’re sure there are more African billionaires that could be ‘encouraged’ to contribute.  Perhaps the recently created WHO Foundation can serve as a resource pooling fund with contributions from billionaires and philanthropists to go towards filling the gap created by the U.S. decision.  For this effort to succeed, major individual donors need to rally behind the WHO.

As the world is grappling with a pandemic, now is not the time for the United States (nor any other high-income country) to defund or halt funding to the WHO or any humanitarian organization working toward controlling the spread of COVID-19 and other diseases. It is instead a time for allies and philanthropies to unite in their efforts to defeat this pandemic without exacerbating other disease threats and support the WHO.

When we, hopefully, one day move beyond Covid-19, the recent actions by the U.S. should also serve as yet another  wakeup call that the current funding system makes the WHO vulnerable to the whims of its biggest donors, whether big countries or influential philanthropic entities. In addition, for programs currently depending on WHO funding in LMICs, including in sub-Saharan Africa, it’s probably also time to think of another and more sustainable way of funding them. Maybe one step forward could be framing funding to the WHO (and health systems in SSA) as an “investment” by countries to keep the globe safe, or a global public good (rather than a generous donation that can be revoked when the mood strikes). Another step forward, probably even more important, is to boost fiscal space and domestic revenue for health in LMICs by tackling tax havens, increasing domestic taxation, prioritizing the health sector over defense, … obviously after another (very much needed) large-scale round of  debt relief for the many countries currently in hot water. These actions will enable governments to take charge of their own health systems instead of requiring continuous international support.  

By the way, to a large extent they boil down to a more structured and sustainable way to “let billionaires contribute to health” in their countries and globally.

About Hiwote Solomon

Boston University School of Public Health, Boston, MA, USA

About Salma M. H. Abdalla

Salma M Abdalla is interested in foundational causes and determinants of health and the role of policies beyond the healthcare sector in shaping population health. She is the lead Project Director for the Rockefeller Foundation-Boston University Commission on health Determinants, Data, and Decision-making (3-D Commission). @SalmaMHAbdalla
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